Every finding on record at Choice Home Health Care

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 6/26/2023 through 6/29/2023. The unduplicated census in the last 12 months was 2842. The census at the time of the survey was 417. The survey sample size was 17 with 10 record reviews and 7 home visits with record reviews. Representing the California Department of Public Health: 35386, Health Facilities Evaluator Nurse; and 44185, Health Facilities Evaluator Nurse.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to inform one family member (FM) about the California Department of Public Health (CDPH) toll-free home health hotline telephone number and it's purpose for filing complaints for one of 7 home visit patients (Patient 15). This failure had the potential to delay the complaint process and compromise patient rights. Review of Patient 15's clinical record indicated, Patient 15 was a ninety-two year old female with diagnoses including stage 4 pressure ulcer (deep wound reaching the muscles, ligaments, or bones) of the sacral region (at the bottom of the spine), alzheimer's disease (progressive disease that destroys memory and other important mental functions) with late onset and dementia (memory loss) with other behavioral disturbance. Her start of care (SOC) was 12/9/22. Patient 15's power of attorney (POA) was her FM. During a home visit observation of Patient 15 on 6/28/23 at 12:30 p.m., with licensed vocational nurse A (LVN A), Patient 15 was laying in her bed, alert but confused and unable to answer questions when asked. No HHA admission packet could be found in Patient 15's home. During an interview on 6/28/23 at 1:15 p.m., with Patient 15's caregiver, she stated, the HHA's admission packet was with Patient 15's FM. During a telephone interview on 6/28/23 at 3:05 p.m., with Patient 15's FM, FM stated she was provided with the HHA's admission packet but was not informed of the CDPH toll-free home health hotline telephone number to report complaints. FM then asked for that telephone number, in case she had complaints for the agency. During an interview with administrator/director of patient care services (ADM/DPCS), on 6/29/23 at 11:22 a.m., ADM/DPCS verified that FM of Patient 15 should have been informed of the CDPH toll-free home health hotline telephone number. She further verified that the visiting clinicians should have reminded Patient 15's FM, about the CDPH toll-free home health hotline telephone number for filing complaints. ADM/DPCS then stated she would remind HHA staffs about this. Review of the HHA's policy and procedure entitled, "Home Care Bill of Rights/Grievance Procedure," last reviewed, 12/2018, indicated, "Patients will be informed of their right to voice grievances and request changes without discrimination, reprisal, or unreasonable interruption of service. Agency will provide a mechanism in which a patient's complaint or grievance can be processed and resolved promptly and efficiently. If the grievance has not been resolved at the above levels or any time during the process, the complainant may contact: The office of Health Facilities/Home Health Agency Hotline:California State Department of Health."

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the initial assessment visit was done within 48 hours of the physician referral date for two of 17 patients (Patients 4 and 13). This failure had the potential to result in less than optimal care for patients who were home bound and in need of home health services. 2. Review of Patient 13’s Patient Information Report indicated a referral date of 5/5/23. Review of Patient 13's POC for the certification period, 5/25/23 through 7/23/23, indicated a SOC date of 5/25/23 and diagnoses of subdural hematoma with loss of consciousness (blood between the brain and its outermost covering, a result of a head injury) and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). The POC further indicated disciplines ordered were for physical therapy (PT) one visit per week times one week and two visits per week times 8 weeks. Review of Patient 13's Client Scheduling Calendar Report indicated SOC visit was done by PT on 5/25/23. During a concurrent record review and interview on 6/28/23 at 11:12 a.m., with the administrator/director of patient care services (ADM/DPCS), ADM/DPCS acknowledged the SOC visit was not made within 48 hours of referral and there was no documentation the doctor was notified. ADM/DPCS stated the patient was discharged from inpatient rehab on 5/16/23 and we received the referral on that day. ADM/DPCS further stated our clinician tried to go out on 5/17/23 but the patient wanted the following week (5/25/23) because he had an appointment on 5/17/23. ADM/DPCS further stated the clinician verbally notified the doctor of the delayed SOC but did not document it. ADM/DPCS further stated it should have been documented. Review of the home health agency's policy and procedure entitled, "Admission Criteria and Process," revised, April 2021, indicated, "The clinical supervisor/nursing supervisor will assign clinical organization personnel to conduct initial assessments of eligibility for services within 48 hours of acceptance of referral information and/or discharge from referring facility. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient's return to home or on the start of care date ordered by the physician or other authorized licensed independent practitioner. In the event that the time frame for the assessment cannot be met, the patient's physician, the referral source and the patient, will be notified for the approval of the delay. Such notification and approval will be documented." 1. Review of Patient 4's clinical record, indicated, Patient 4 was a 91 year old female with diagnoses, including hypothyroidism (thyroid hormone deficiency), dementia (memory loss) without behaviors, hypertension (high blood pressure) and atrial fibrillation (irregular heart rhythm). Review of Patient 4's information report indicated, her referral date was 3/2/23. Patient 4's plan of care (POC) for the certification period, 4/3/23 to 6/1/23 indicated, her start of care (SOC) date was 4/3/23. During the concurrent record review and interview with the administrator/director of patient care services (ADM/DPCS) on 6/9/23 at 12:00 p.m., ADM/DPCS verified the late SOC of Patient 4. She further verified that the SOC was not done within 48 hours of the referral of Patient 4 and the physician was not notified and there was no coordination note for the late SOC of Patient 4. ADM/DPCS also stated that the physician should have been notified and a coordination note should have been made for the late SOC.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the home health agency (HHA) failed to ensure an accurate comprehensive medication profile included all prescribed and over-the-counter medications when the medications in the home did not match the medication profile list for two of 7 home visit patients (Patients 11 and 13). Failure to review and update the medication profile list had the potential to result in negative patient outcomes associated with medication discrepancies. 1. Review of Patient 11’s plan of care (POC) for the certification period, 6/12/23 through 8/10/23, indicated a start of care (SOC) date of 6/12/23 and diagnoses of anemia (a condition marked by a deficiency of red blood cells in the blood, resulting in weariness) and gastrointestinal hemorrhage (bleeding in your digestive tract). The POC further indicated disciplines ordered were for skilled nursing (SN) one visit per week times 5 weeks, physical therapy (PT) one visit per week times 1 week and two visits per week times 8 weeks, occupational therapy (OT) one visit per week times 1 week, and medical social worker (MSW) one visit per week times 4 weeks. During a medication reconciliation (comparison of the medications in the home to those on the medication profile list) at a home visit on 6/27/23 at 11:30 a.m., with Patient 11 and medical social worker B (MSW B), the following medications were found in Patient 11's home but were not listed on the medication profile list: Vitamin E (a nutrient needed for immune health) 80 mg (mg, a dose measurement); Ferrous Sulfate (iron supplement used to treat or prevent low levels of iron such as those caused by anemia) 325 mg; Alpha Lipoic Acid (a medication used as an antioxidant) 200 mg; Vitamin D3 (a supplement) 25 mcg (mcg, a dose measurement); Vitamin K2 (a nutrient that benefits bone and heart health) 100 mcg; Magnesium (a nutrient important for many processes in the body); Crestor (used to treat high cholesterol and reduce the risk of heart attack, stroke, and related health conditions) 20 mg; and Anoro (used to promote better breathing) one puff. During a concurrent interview with Patient 11, she stated she takes one Vitamin E every morning, one Ferrous Sulfate two times per day, one Alpha Lipoic Acid one time per day, one Vitamin D3 one time per day, one Vitamin K2 one time per day, one Crestor one time per day and one puff of Anoro daily for neighbors smoking upstairs. During an interview on 6/27/23, at 12:30 p.m., with MSW B, MSW B acknowledged the discrepancies and she stated she is not responsible for medications. 2. Review of Patient 13’s POC for the certification period, 5/25/23 through 7/23/23, indicated a SOC date of 5/25/23 and diagnoses of subdural hematoma with loss of consciousness (blood between the brain and its outermost covering, a result of a head injury) and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). The POC further indicated disciplines ordered were for physical therapy (PT) one visit one time per week and two visits per week times 8 weeks. During a medication reconciliation at a home visit on 6/27/23 at 2:30 p.m., with Patient 13 and physical therapy assistant C (PTA C), the medication profile list indicated the following: Erythromycin (used to treat bacterial infections of the eye) 5 mg eye ointment apply daily; Sevelamer carbonate (used to control high levels of phosphorus in blood in people with chronic kidney disease) 800 mg three tablets three times per day; and Veltassa (used to treat high levels of potassium in blood) 8.4 gram (gm, a dose measurement) oral powder packet one packet daily. Vitamin D3 (a supplement) 50 mcg was found in Patient 13's home but was not listed on the medication profile list and one bottle of carvedilol (used to treat high blood pressure) had an expiration date of 7/21/22. During a concurrent interview with Patient 13, he stated he applies the Erythromycin as needed, takes three tablets of Sevelamer two times per day, Veltassa one packet three times per week, and one tablet of Vitamin D3 daily. During an interview on 6/29/23 at 11:31 a.m., with clinical manager E (CM E), CM E stated clinicians should be checking the bottles in the home against the medication profile list and any discrepancies should be reported to the doctor. CM E acknowledged clinicians should also be checking expiration dates on the bottles and she stated if expired medications are found in the home the clinicians should instruct patients on how to dispose of them. Review of the agency's policy revised April 2021, "Medication Profile", indicated patients will have a current, accurate medication profile in the clinical record and medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. Review of the agency's policy revised April 2021, "Administration and Documentation of Medications", indicated as part of the assessment process, a drug history will be taken, including prescribed and over-the-counter medications, and herbal and nutritional supplements. It further indicated a comparison will be made between the physician's orders and the current medications the patient is taking. It further indicated any discrepancies would be reported to the physician for resolution.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on interview and record the home health agency (HHA) failed to ensure a vaccination history assessment was done on admission for one of 17 patients (Patient 5) and; failed to maintain a written policy on vaccination screening, administration and managing of adverse reactions for influenza (FLU, a contagious viral infection, most severe in the winter season) and pneumococcal (PNA, infection and inflammation of the lungs, may be caused by influenza) vaccines [VAC, a preparation containing killed or weakened microorganisms (bacteria or viruses) usually given by injection to increase protection against a particular disease]. This failure had the potential to lead to unsafe and ineffective administration of FLU and PNA vaccines. Review of Patient 5’s plan of care (POC) for the certification period, 3/31/23 through 5/29/23, indicated a start of care (SOC) date of 3/31/23 and diagnoses of pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of right buttock, stage 2 (partial thickness loss presenting as a shallow open ulcer or as an intact open/ruptured blister). The POC further indicated disciplines ordered were for skilled nursing (SN) one visit per week times 9 weeks. During an interview on 6/29/23 at 8:05 a.m. with the administrator/director of patient care services (ADM/DPCS), ADM/DPCS stated there was no written policy specific to vaccines. ADM/DPCS further stated we do not offer them anymore because we were wasting a lot of vaccine. ADM/DPCS further stated patients were getting them somewhere else. During a subsequent interview on 6/29/23 at 9:20 a.m., with the ADM/DPCS, she stated she could not find Patient 5's vaccination history. During a telephone interview during the exit conference on 6/29/23 at 3:00 p.m. with the director of operations (DO), DO stated it is offered and the issue was regarding screening and if we are going to administer it. DO further stated there have been a lot of changes with the organization. Review of the agency's updated policy, "Patient Admission Process", indicated the intake form shall include at a minimum: Updated Vaccine History. Review of the agency's policy revised April 2021, "Administration and Documentation of Medications", indicated Influenza and Pneumococcal vaccines may be administered in the home by physician order or as permitted by law or regulation according to physician - approved organizational protocol(s). It further indicated the vaccinations may be administered after an assessment of the patient to determine screening contraindications.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review the home health agency (HHA) failed to follow accepted standards of practice to prevent the spread of infection for three of seven home visit patients (Patients 11, 13 and 14) when: For Patient 11, medical social worker B (MSW B) did not place contaminated chux (disposable underpad), gloves and sani-cloth (germicidal wipe) in a secured plastic bag before discarding them in a dumpster outside patient 11's home and; For Patient 13, physical therapy assistant C (PTA C) did not prepare a clean and dirty area near her nursing bag to avoid entering/re-entering the bag, did not routinely perform hand hygiene each time she entered/re-entered the bag, and did not perform hand hygiene before applying and removing her gloves and; For Patient 14, physical therapist D (PT D) did not prepare a clean and dirty area near her nursing bag to avoid entering/re-entering the bag, did not routinely perform hand hygiene each time she entered/re-entered the bag, and did not perform hand hygiene before applying her gloves. These failures had the potential to lead to the spread of infection. 1. Review of Patient 11’s plan of care (POC) for the certification period, 6/12/23 through 8/10/23, indicated a start of care (SOC) date of 6/12/23 and diagnoses of anemia (a condition marked by a deficiency of red blood cells in the blood, resulting in weariness) and gastrointestinal hemorrhage (bleeding in your digestive tract). The POC further indicated disciplines ordered were for skilled nursing (SN) one visit per week times 5 weeks, physical therapy (PT) one visit per week times 1 week and two visits per week times 8 weeks, occupational therapy (OT) one visit per week times 1 week, and medical social worker (MSW) one visit per week times 4 weeks. During an observation on 6/27/23 at 11:30 a.m., at a home visit with Patient 11, and MSW B, MSW B was observed providing care to Patient 11. At the end of the visit MSW B was observed gathering up contaminated items (chux used as a barrier, gloves and sani-cloth used to disinfect her hands and equipment) and carried them outside and placed them in a dumpster. MSW B did not place the contaminated items in a secured plastic bag before disposing of them. During a telephone interview on 6/29/23 at 12:00 p.m., with MSW B, she stated normally she carried a plastic trash bag with her to place her contaminated items in and she knew the patient had that dumpster outside her home. MSW B further stated next time she would secure them in a plastic bag before disposing of them. 2. Review of Patient 13’s POC for the certification period, 5/25/23 through 7/23/23, indicated a SOC date of 5/25/23 and diagnoses of subdural hematoma with loss of consciousness (blood between the brain and its outermost covering, a result of a head injury) and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). The POC further indicated disciplines ordered were for physical therapy (PT) one visit one time per week and two visits per week times 8 weeks. During an observation on 6/27/23 at 2:30 p.m., at a home visit with Patient 13 and PTA C, PTA C was observed providing care to Patient 13. PTA C applied gloves and reached into her nursing bag to remove items from the bag to take Patient 13's blood pressure, temperature and oxygen saturation. PTA C did not sanitize her hands before applying her gloves and did not prepare a clean area near her bag to put out the things most needed e.g., blood pressure cuff, stethoscope, thermometer and pulse oximeter to make them readily accessible, and to avoid using the bag as few times as possible. After PTA C used an item she sanitized it with a sani-cloth (germicidal wipe) and returned the equipment back into the bag. PTA C did not routinely perform hand hygiene each time she entered or re-entered the nursing bag to remove and replace an item from the bag. At the end of the visit PTA C did not sanitize her hands after she removed her gloves. During an interview on 6/27/23 at 3:30 p.m., with PTA C, PTA C acknowledged she should sanitize her hands with hand sanitizer before putting on and taking off her gloves and she stated she should leave her hand sanitizer out. PTA also stated she had not been signed off on nursing bag technique. 3. Review of Patient 14's POC for the certification period, 5/2/23 through 6/30/23, indicated a SOC date of 11/13/20 and diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar) with Diabetic Polyneuropathy (peripheral nerve dysfunction). The POC further indicated disciplines ordered were for physical therapy (PT) one visit per week times 8 weeks. During an observation on 6/28/23 at 1:30 p.m., with Patient 14 and PT D, PT D was observed applying a pair of gloves and taking Patient 14's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's bodily functions). PT D did not sanitize her hands before applying her gloves, did not prepare a clean or dirty area near her bag to place her clean and dirty equipment on to avoid entering and re-entering the bag as few times as possible, did not routinely perform hand hygiene each time she entered/re-entered her bag, and did not perform hand hygiene before applying her gloves. During an interview on 6/29/23 at 11:31 a.m., with clinical manager E (CM E), CM E stated clinicians should perform hand hygiene prior to removing items from the bag. CM E further stated they should remove the needed items for the visit and place them on a clean barrier to avoid entering and re-entering the bag multiple times. CM E further stated following use reusable/contaminated items should be placed on a dirty barrier, sanitized and then returned to the bag. CM E further stated clinicians should sanitize their hands before and after removing their gloves and they should use hand sanitizer to sanitize their hands. Review of the agency's policy revised April 2021, "Bag Technique", indicated prior to administering care, alcohol-based hand rub will be removed, and hands will be washed....hand washing will always be completed before opening the bag.... after hand washing, the supplies and /or equipment needed for the visit will be removed from the bag..... when the visit is completed, reusable equipment will be cleaned using alcohol, or other appropriate solution.....hands will be washed and equipment and supplies will be returned to the bag. Review of the agency's policy revised April 2021, "Contaminated Waste Disposal", indicated contaminated paper wastes (disposable gloves, masks, paper towel, etc.) should be placed in a plastic puncture resistant bag and secured...and placed in a plastic trash container." Review of the agency's policy revised April 2021, "Hand Hygiene", indicated personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC regulations and guidelines for hand hygiene in healthcare settings...when hands ae not visibly soiled, they should be washed using an alcohol-based hand rub for routinely decontaminating hands...hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patients..after contact with a patient's intact skin (when taking a pulse or blood pressure)...and after removing gloves.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to develop and implement written policies and procedures to ensure that all staff are fully vaccinated for COVID-19 (an acute disease in humans caused by a coronavirus and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions). This failure had the potential to lead to required staff not being fully vaccinated against COVID-19 and the spread of infection. During a concurrent review of the HHA's list of staff and COVID-19 vaccine status, and interview on 6/29/23 at 10:45 a.m., with Clinical Manager F (CM F), CM F did not know when a clinician was considered fully vaccinated or if the agency had achieved a 100% vaccination rate of their staff. CM F further stated she was new to the organization. CM F also could not provide a policy and procedure to address COVID-19 vaccination to ensure all staff are fully vaccinated and she stated corporate was still looking for it. Review of the agency's 08/01/2022, "Coronavirus COVID-19+ Surveillance and Testing Protocols", indicated employees are required to be fully vaccinated per CDC and CDPH requirements and for those employees seeking medical or religious exemption, see exemption policy. Review of the agency's revised/reviewed 08/01/2022 policy, "Pandemic Infectious Disease Surveillance, testing, PUI Tracking, Vaccination Protocols" did not include or address a process for ensuring all staff are fully vaccinated for COVID-19 or a process by which staff may request an exemption (exemption policy) from the COVID-19 vaccination requirement. Review of the Home Health Agency (HHA) Attachment to be used in conjunction with QSO 22-07-ALL dated 12/28/21 memorandum: Guidance for the Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination indicated all HHAs are required to achieve100% vaccination for their staff through the development of a policy to address vaccination applicable to all staff who provide any care, treatment, or other services for the HHA and/or its patients.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide services as indicated in the plan of care (POC) for one of 17 patients (Patient 2) when Patient 2 missed one skilled nursing (SN) visit and the reason for the missed visit was not documented and the change in the physician's order frequency was not reported to the physician. This failure had the potential to result in the HHA's inability to ensure needed services and high-quality healthcare were provided. Review of Patient 2's clinical record indicated, she was a 99 year old female with diagnoses including type 2 diabetes (a condition in which the blood sugar levels are too high) with diabetic peripheral angiopathy (damage to cells in the blood vessels due to high blood sugar) without gangrene (dead tissue caused by infection or lack of blood flow). Her start of care (SOC) date was 1/7/23. Review of Patient 2's plan of care (POC) for the certification period, 1/7/23 through 3/7/23, indicated disciplines ordered were skilled nursing (SN), physical therapist (PT) and occupational therapist (OT). SN visit frequency order was once per week for four weeks. Review of Patient 2's client scheduling calendar report for the certification period, 1/7/23 through 3/7/23, indicated there was a missed skilled nursing visit for the week of 1/22/23 to 1/28/23. During a concurrent record review and interview on 6/29/23 at 11:55 a.m., with the administrator/director of patient care services (ADM/DPCS), ADM/DPCS verified the missed skilled nursing visit. ADM/DPCS further verified the doctor was not notified of the missed visit and there was no documentation in a coordination note with the reason why the visit was missed. Review of the home health agency's undated policy and procedure entitled, "Clinical Documentation," indicated, "Services not provided and the reason for the missed visits will be documented and reported to the physician. Missed visits are a change in the physician's orders frequency and duration. The physician needs to be notified of any changes in the frequency and duration."

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure a visit note was completed in a timely manner for one of 17 patients (Patient 6). Failure to complete visit notes in a timely manner could result in a delay in the coordination of care. Review of Patient 6's plan of care (POC) for the certification period, 5/17/23 through 7/15/23, indicated, Patient 6 was a 55 year old male with a start of care (SOC) date of 4/18/17 and diagnoses, including stage 4 pressure ulcer (deep wound reaching the muscles, ligaments, or bones) of the sacral region (at the bottom of the spine). The POC further indicated, discipline ordered was SN, two visits per week for eight weeks. During a concurrent record review and interview on 6/29/23 at 12:10 p.m., with the administrator/director of patient care services (ADM/DPCS), a skilled nursing (SN) visit was made on 6/19/23 and the SN visit note, was still not completed as of 6/29/23, more than 72 hours from the visit. ADM/DPCS verified that the SN visit note was still not completed. She further verified that it should have been completed and should have been done in a timely manner. Review of the home health agency's undated policy and procedure entitled, "Clinical Documentation," indicated, "Agency will document each direct contact with the patient. Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into the clinical record within 48-72 hours after the care has been provided."